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Diarrhoea in children and adolescentsPaediatrics > Gastroenterology > Diarrhoea in children and adolescents

Published: 15-Dec-2016 Valid until: 31-Dec-2018 Printed on: 13-Nov-2017 © Map of Medicine Ltd This care map was published by Qatar. A printed version of this document is not controlled so may not be up-to-date with the latest clinicalinformation.

Page 1 of 13

Backgroundinformation

Updates to this caremap

Key recommendationsof the care map

Abbreviations used inthe care map

Clinical presentation

History andExamination

Stool microbiology

Assess for dehydration

IV rehydration Oral rehydration

Following rehydration

Consider antimicrobialtherapy

Probiotics and othermedication

Provide education andadvice

Consider referralto the EmergencyDepartment

Other investigations

Differential diagnosis

Follow up and notifyMoPH Public Health

Follow up



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1 Background information

Quick info:The purpose of this care map is to define the appropriate diagnosis and management of acute diarrhoea in children. The objective isto reduce inappropriate investigation, prescribing, and referral of patients presenting to provider organisations in Qatar. It is intendedthat the care map will be used primarily by physicians in primary care and outpatient settings.Scope of the care map:

• Diagnosis and management of symptoms of acute diarrhoea in children.

• Differential diagnosis of acute and persistent diarrhoea.

• Assessment and management of dehydration in children with diarrhoea.

• The appropriate use of antimicrobials in the management of acute diarrhoea.

• Advice to caregivers.

• Public health obligations of healthcare professionals in relation to acute diarrhoea.

Aspects of care not covered in this care map are:

• Dehydration in children without diarrhoea.

• Management of infectious diarrhoea causing outbreaks in health care settings.

• Detailed prescribing of intravenous fluids for dehydrated patients.

Definitions:Diarrhoea is defined as:

• The passage of loose or liquid stools, usually associated with an increase in stool frequency and volume (more than 3 timesdaily) [1].

However, stool frequency and consistency also varies between well children and an increase in frequency and softness of stool mayindicate acute diarrhoea [1]. Stools also tend to be softer and more frequent in breastfed infants than those that are bottle fed [1].Acute diarrhoea is defined as:

• 3 or more episodes of loose or liquid stools in one day, usually lasting less than 7 and not more than 14 days [2].

Persistent diarrhoea is defined as:

• An episode of diarrhoea that lasts for more than 14 days [3].

NB: Diarrhoea is a symptom rather than a diagnosis, which in the majority of cases is found to be related to acute gastroenteritis [R-GDG].Aetiology:Reliable data on the incidence of acute diarrhoea in children is presently lacking in Qatar. However, norovirus is considered aleading cause of acute gastroenteritis in the general population in Qatar [4]. Adenovirus is also a commonly detected viral pathogenisolated in children under the age of 5 years [4].Pathogens causing acute diarrhoea in children include [3]:

• Norovirus.

• Rotavirus.

• Adenovirus.

• Astrovirus.

• Cytomegalovirus.

• Escherichia coli.

• Campylobacter jejuni.

• Shigella species.

• Clostridium difficile.

• Non typhoidal Salmonellae.

• Yersinia enterocolitica.

• Vibrio cholerae.

• Cryptosporidium parvum.

• Giardia intestinalis.

• Entamoeba histolytica.



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Studies carried out in the Qatar population have identified that breastfeeding is a factor reducing the incidence and severity ofinfantile diarrhoea in the first 6 months of life [5,6].References:Please see the care map's Provenance.

2 Updates to this care map

Quick info:Date of publication: 08-Dec-2016Please see the care map's Provenance for additional information on references, contributors and the editorial approach.

3 Key recommendations of the care map

Quick info:The key recommendations of this care map are:Investigations:

• Refer to the 'Stool microbiology' care point for specific indications for stool microscopy and culture.

• Do not routinely carry out blood biochemical tests in children with gastroenteritis to assess for dehydration [1][L2, RGB].

Rehydration:

• Unless intravenous fluids are needed, ORS solution should be used for rehydration, including for those with hypernatraemia [1][L1, RGA1].

• During rehydration, breastfed babies should continue breastfeeding [1][L2, RGA2].

• If oral rehydration fails, hospital admission is recommended [2][L3, RGA2].

• Routine use of lactose-free feeds is not recommended in patients managed in the community [2][L1, RGB].

Antimicrobial treatments:

• Do not routinely give antimicrobials to children with acute diarrhoea [1,2][L3].

• Antimicrobials are recommended for children with suspected septicaemia or extra−intestinal spread of bacterial infections [5].

Probiotics:

• Probiotics, used as an adjunct to rehydration therapy, have been shown to reduce duration and severity of symptoms of acutegastroenteritis [2][L1, RGA1].

• A recent Cochrane review concluded that there is limited evidence suggesting probiotics may be effective in treatment ofpersistent diarrhoea in children [13].

Other medications:

• Anti-emetics and anti-diarrhoeal medications are not routinely recommended for children with acute gastroenteritis [1,2].

• Zinc supplementation may be considered alongside ORS in children with acute gastroenteritis [2,3].

Education and advice to care givers:

• Refer to the 'Provide education and advice' care point for specific advice to be given to caregivers on aspects of hygiene and

safety−netting.

Follow up:

• Further assessment should be considered if there is no improvement within 48 hours, or there is worsening of the child’s overallcondition [3].

• Appropriate notification to Public Health should be made online if notifiable diseases are detected or suspected [16].

Referral to secondary/specialist care:

• Refer to the 'Consider referral to secondary care/specialist' care point for specific referral criteria to secondary/specialist care.

References:Please see the care map's Provenance.

4 Abbreviations used in the care map



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Quick info:The abbreviations used in this care map are as follows:FPIESFood protein induced enteropathic syndromeIVIntravenous routeMoPHMinistry of Public Health of QatarORSOral rehydration salt solution

5 Clinical presentation

Quick info:Diarrhoea is defined as:

• The passage of loose or liquid stools, usually associated with an increase in stool frequency and volume (more than 3 timesdaily) [1].

However, stool frequency and consistency also varies between well children and an increase in frequency and softness of stool mayindicate acute diarrhoea [1]. Stools also tend to be softer and more frequent in breastfed infants than those that are bottle fed [1].NB: Diarrhoea is a symptom rather than a diagnosis, which in the majority of cases is found to be related to acute gastroenteritis [R-GDG].References:Please see the care map's Provenance.

6 History and Examination

Quick info:The following key points in the history should be elicited and recorded where relevant [1,3]:

• Onset of diarrhoea.

• Stool frequency.

• Nature and volume of stool.

• Nausea and vomiting.

• Fever.

• Abdominal pain or distension.

• Appetite.

• Previous medical history.

• Underlying conditions.

• Presence of blood in the stool.

• Exposure to potential sources of infectious pathogens:

• Recent contact with someone with acute diarrhoea and/or vomiting.

• Contaminated water or food:

• May be suspected by affected persons sharing the same water source/meal.

• Recent travel abroad.

• Contact with ruminant animals (such as camels, cattle, goats, and sheep), their faeces and any faecally−contaminatedenvironments.

• Medication review.

Examine for and record the following [1,3]:

• Body weight, and comparison with recent recorded weight, if available.

• Temperature, heart rate, and respiratory rate.

• Blood pressure (where available).



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• Abdominal examination.

• Level of consciousness.

• Assess for clinical features of dehydration and shock [1]:

• Features of clinical dehydration:

• Appears to be unwell or deteriorating*.

• Altered responsiveness – irritable, lethargic*.

• Decreased urine output.

• Sunken eyes*.

• Dry mucous membranes – take mouth breathing into account.

• Tachycardia*.

• Tachypnoea*.

• Reduced skin turgor*.

• Features of clinical shock* – usually indicated by increased severity in symptoms of moderate dehydration, plus:

• Decreased consciousness.

• Pale or mottled skin.

• Weak peripheral pulses.

• Prolonged capillary refill time (>2 secs).

• Hypotension – decompensated shock.

*Red flag features that help to identify children at increased risk of progression to shock.NB: There is a spectrum of severity for children who have features of clinical dehydration; increased severity is indicated byincreasingly numerous and more pronounced features [1].The following features may indicate the patient is at an increased risk of dehydration [1]:

• Younger than 1 year, particularly those younger than 6 months of age.

• Infants of low birth weight.

• More than five diarrhoeal stools in the previous 24 hours.

• Protracted vomiting in the previous 24 hours.

• Children who have not able to tolerate supplementary fluids prior to presentation.

• Infants who have stopped breastfeeding during the illness.

• Signs of malnutrition.

• History of chronic gastrointestinal or renal disease.


7 Differential diagnosis

Quick info:The differential diagnosis of acute diarrhoea includes [1,7]:

• Gastrointestinal infections:

• Viral – most common.

• Bacterial.

• Parasitic.

• Non−gastrointestinal infections:

• Pneumonia:

• Cough, shortness of breath, chest pain, tachypnoea, tachycardia.

• Urinary tract infection:

• Frequency, dysuria.

• Acute otitis media:

• Earache.



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• Meningitis:

• Persistent vomiting, altered consciousness, irritability, photophobia, petechial purpuric rash, neck stiffness, bulgingfontanelle in infants.

• Immunodeficiency.

• Surgical causes:

• Consider if patient presents with the following [1]:

• Bilious vomiting.

• Severe or localised abdominal pain.

• Mucoid/bloody stools.

• Abdominal distension.

• Rebound tenderness.

• Diagnoses include [1,8]:

• Appendicitis.

• Intussusception.

• Bowel obstruction.

• Short bowel syndrome.

• Ischaemic bowel.

Differential diagnoses of a first−time presentation of persistent diarrhoea:

• Non−infective gastrointestinal disorders:

• Suspect particularly if the patient presents with the following [1]:

• Bloody diarrhoea.

• Failure to thrive.

• Weight loss.

• Causes include [1,7,9]:

• Inflammatory bowel disease.

• Coeliac disease.

• Hirschsprung's enterocolitis.

• Consider endocrinopathy [8]:

• Diabetes mellitus.

• Hyperthyroidism.

• Congenital adrenal hyperplasia.

• Addison's disease.

• Hypoparathyroidism.

• Consider drug related causes [1,7,10,12]:

• Antibiotics.

• Antimalarials.

• Magnesium−containing antacids.

• Laxative abuse.

• Consider dietary disturbance [1,10]:

• Food hypersensitivity and/or allergy, e.g.:

• Congenital lactose intolerance.

• Transient lactose intolerance following an episode of gastroenteritis.

• Cow's milk protein – IgE or non−IgE mediated.

• Sorbitol (toddler’s diarrhoea).

• Food protein induced enteropathic syndrome (FPIES) − severe presentation.

• Consider other non−coeliac causes of malabsorption [1].



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• Consider idiopathic/psychogenic causes [7]:

• Irritable bowel syndrome.

• Bulimia.

• Consider secretory tumours [7]:

• Carcinoid tumours.

• Medullary tumour of the thyroid.

• Vasoactive intestinal peptide−secreting adenomas.

• Other causes [1,8,10]:

• Constipation with overflow diarrhoea, especially in older children.


8 Consider referral to the Emergency Department

Quick info:Consider referral to secondary/specialist care for children with any of the following [1-3]:

• Alarm symptoms/signs are present:

• The child appears to be unwell or deteriorating.

• Fever:

• Temperature of 38°C or higher in children younger than 3 months.

• Temperature of 39°C or higher in children aged 3 months and older.

• Tachypnoea.

• Altered consciousness.

• Neck stiffness.

• Sunken eyes.

• Reduced skin turgor – 1−2 seconds to recoil from pinch of skin.

• Bulging or depressed fontanelle in infants.

• Non−blanching rash.

• Blood and/or mucus in stool.

• Bilious (green) vomiting.

• Severe or localised abdominal pain.

• Abdominal distension or rebound tenderness.

• Urticaria − suggests systemic allergic reaction.

• An increased risk of dehydration, e.g. [1][L3, RGA2]:

• Younger than age 1 year, particularly those younger than age 6 months.



• More than two vomits in the previous 24 hours.

• Children who have not been offered or been able to tolerate supplementary fluids prior to presentation.

• Infants who have stopped breastfeeding during the illness.

• Signs of malnutrition.

• Changing mental status.

• A history of premature birth.

• Chronic medical conditions, e.g. severe cardiac or renal disease.

• Concurrent illness.

• High output diarrhoea, including frequent and substantial volumes.

• No improvement in 48 hours, or a worsening overall condition.



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• No urine output in the previous 12 hours.


9 Follow up and notify MoPH Public Health

Quick info:Notification of the MoPH Public Health Communicable Disease Department should be made, before stool samples are resulted, inthe following circumstances. If Public Health notification is planned, stool sample should be taken from affected individuals in orderto assist in the identification of the causative agent [16]:

• If diarrhoea has been reported in ≥2 children/persons in close contact, especially if:

• Individuals have shared the same meal; or

• Had contact during a social event e.g. a social gathering/party; or

• Contact has occurred in a school or similar setting.

Contact details of the child’s parents/carers, or of any other affected people, should be supplied to the MoPH Public HealthDepartment in order for them to verify patient symptoms, identify locations of the affected persons, and determine whether furtherinvestigation is required.Contact the MoPH Public Health Communicable Disease Department using any of the following:

• Email: [email protected]

• Telephone (during working hours): 04 407 0155; 04 407 0184; 04 407 0195.

• Fax: 04 407 0812;

• Hotlines (urgent queries only): 06 674 0948 / 06 674 0951.


10 Stool microbiology

Quick info:Consider stool microscopy (with or without ova and parasites or rotavirus antigen testing) if the following are present [1,2][L3]:

• Suspected food poisoning (see the 'Follow up and notify MoPH Public Health' care point on notification of Public Health).

• Persistent diarrhoea for more than 3−5 days.

• Fever.

• Abdominal pain.

• Mucus or blood in the stool.

• Recent travel.

• Uncertainty about a diagnosis of gastroenteritis.

• The child has underlying chronic gastroenterological, renal, or other conditions.

Consider performing a stool culture if acute diarrhoea is present and [1,10][L3]:

• Food poisoning is suspected (see the 'Follow up and notify MoPH Public Health' care point on notification of Public Health).

• The child is systemically unwell.

• Hospital admission is indicated.

• Abdominal pain.

• Fever.

• Mucus or blood is reported in the stool.

• The child is immunocompromised.

• There is a history of:

• Recent antibiotic use.

• Chronic proton pump inhibitor use.

• Recent hospital admission (in the last two months).

mailto:[email protected]



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A repeat sample is not usually required unless [11][L3]:

• Ova or parasites are suspected.

• Repeat sample has been advised by a microbiologist.

• Diarrhoea lasts for more than 7 days after the initial visit [R-GDG].


11 Other investigations

Quick info:Do not routinely carry out blood biochemical tests in children with gastroenteritis to assess for dehydration [1][L2, RGB].The following additional investigations may be appropriate:

• Blood cultures:

• Standard practice is to carry out blood cultures if commencing antibiotic therapy for suspected or confirmed bacterialdiarrhoea [1][L3].

• Blood tests (e.g. urea, electrolytes, creatinine, and glucose):

• Tests may be carried out in selected cases such as:

• In moderately dehydrated or severely dehydrated children [2][L3, RGA2].

• In children starting and undergoing intravenous therapy [1,2][L3, RGA2].

• If hypernatraemia is suspected [1][L3].

• Urinalysis [R-GDG].

• Endoscopy:

• May be indicated in selected cases, such as when inflammatory bowel disease is suspected, but it is not routinelyrecommended [2][L3, RGA2].

• Abdominal imaging − if surgical causes of diarrhoea are suspected [R-GDG].


12 Assess for dehydration

Quick info:For children without clinical symptoms or signs of dehydration [1][L2, RGA1]:

• Advise continuing with usual feeds, including breastfeeding and other milk feeds.

• Encourage fluid intake.

• Discourage drinking fruit juice or carbonated drinks.

• Offer ORS as a supplemental fluid to children at increased risk of dehydration.


13 Provide education and advice

Quick info:Advise parents/carers [1][L3]:

• That the usual duration of diarrhoea in acute gastroenteritis is 5-7 days, and should stop within 2 weeks.

• That the usual duration of vomiting in acute gastroenteritis is 1-2 days and should stop within 3 days.

• That advice should be sought from a healthcare professional if symptoms do not resolve within these time frames.

• How to access medical help.

• How to recognise symptoms and signs of dehydration.

• To seek immediate help from a healthcare professional if symptoms of dehydration develop, such as:



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• Appearing to get more unwell.

• Changing responsiveness, e.g. irritability, lethargy.

• Decreased urine output.

• Pale or mottled skin.

• Cold extremities.

• Advise on follow-up arrangements if necessary, specifying time and place [1][L3].

• Advise parents/carers and children to [1,14]:

• Wash hands thoroughly with soap in warm running water and dry carefully.

• Avoid sharing towels used by infected children.

• Wash soiled clothing and linen separately from other clothes at the highest temperatures they will tolerate.

• Remain absent from school or other childcare facilities while the patient has diarrhoea or vomiting, or within 48 hours of thelast episode.

• Extend period of childcare facility absence until there is evidence of microbiological clearance in cases where [15]:

• The child is infected with Escherichia coli, Typhoid, or Shigella, and the child is either aged 5 years or younger, or hasdifficulty adhering to hygiene practices.

• Avoid swimming pools for 2 weeks after the last episode of diarrhoea [1][L3]:

• Particularly if cryptosporidiosis is suspected or confirmed [15].


14 Consider antimicrobial therapy

Quick info:Antimicrobial treatment:

• Do not routinely give antimicrobials to children with acute diarrhoea [1,2][L3].

• Seek specialist advice when [1]:

• The child has recently been abroad.

• Stool culture reveals a causative organism.

• Consider antimicrobial treatment (following stool sampling) for infectious causes of acute diarrhoea, including [1]:

• Salmonella gastroenteritis, if the child is:

• Younger than age 6 months; or

• Malnourished; or

• Immunocompromised.

• Clostridium difficile-associated pseudomembranous enterocolitis.

• Campylobacter jejuni [R-GDG].

• Giardiasis [1][L3].

• Dysenteric shigellosis [1,2][L1, RGA1].

• Dysenteric amoebiasis [1][L3].

• Cholera [1,2][L1, RGA1].

• Antimicrobials are recommended for children with suspected septicaemia or extra-intestinal spread of bacterial infections [5].

• Note that parenteral rather than oral antimicrobials are indicated if [2][L3, RGA2]:

• The child is unable to take oral medication.

• The child has an immune deficiency and presents with acute gastroenteritis and fever.

• Severe septicaemia or bacteraemia is suspected or confirmed.

• Neonates and infants younger than age 3 months present with acute diarrhoea and fever.




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15 Probiotics and other medication

Quick info:Probiotics, used as an adjunct to rehydration therapy, have been shown to reduce duration and severity of symptoms of acutegastroenteritis [2][L1, RGA1]:

• Probiotic effects are strain-specific and so safety and efficacy of each should be established.

• Safety and effectiveness of a single probiotic organism cannot be extrapolated to other organisms.

• A recent Cochrane review concluded that there is limited evidence suggesting probiotics may be effective in treatment ofpersistent diarrhoea in children [13].

The use of prebiotics in the management of acute gastroenteritis in children is not recommended [2][L1, RGA2].The following medication are NOT routinely recommended for children with gastroenteritis [1,2]:

• Anti−emetics for children with nausea and vomiting.

• Anti−diarrhoeal medications for children with diarrhoea:

• Bismuth subsalicylate.

• Folic acid

• Gelatin tannate

• Prebiotics.

• Loperamide.

Zinc supplementation may be considered alongside ORS in children with acute gastroenteritis [2,3].References:Please see the care map's Provenance.

16 IV rehydration

Quick info:IV fluid therapy is recommended if:

• Shock is suspected or confirmed [1][L3].

• Dehydration is associated with altered level of consciousness or severe acidosis [2][L3, RGA2].

• A child with any of the following symptoms/signs shows clinical deterioration despite oral rehydration therapy [1][L3]:

• The child appears to be unwell or deteriorating.

• Altered responsiveness – irritable/lethargic.

• Sunken eyes.

• Tachycardia.

• Tachypnoea.

• Reduced skin turgor – 1-2 seconds to recoil from pinch of skin.

• A child persistently vomits the ORS solution given orally or via a nasogastric tube [1][L3].

• If child fails to respond to oral rehydration therapy [2][L3].

• Severe abdominal distension and ileus are present [2][L3].

NB: The prescription of IV fluids in secondary care settings is out of scope for this guidance.References:Please see the care map's Provenance.

17 Oral rehydration

Quick info:In children with clinical symptoms or signs of dehydration [1,12]:

• Unless intravenous fluids are needed, ORS solution should be used for rehydration, including for those with hypernatraemia [1][L1, RGA1]:

• Use low osmolarity ORS (240–250 mOsm/L) [1][L1, RGA1]. Examples include:



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• Pedialyte®.

• In children age 5 years or younger, give 50 mL/kg over 4 hours plus maintenance volume.

• In children older than age 5 years, give 200 mL ORS solution after each loose stool.

• Give ORS solution frequently and in small amounts.

• Consider supplementation with the child's usual fluids if they refuse to take sufficient quantities of ORS solution and do not haveserious symptoms and signs.

• Monitor response to rehydration by regular clinical assessment.

Maintenance fluid volume requirements per day [1]:

• Less than 10 kg body weight: 100 mL/kg.

• 10−20 kg body weight: 1L plus 50 mL/kg for each kg over 10 kg.

• More than 20kg body weight: 1.5L plus 20 mL/kg for each kg over 20 kg.

During rehydration:

• Breast−fed babies should continue breastfeeding [1][L2, RGA2].

• Oral fluids other than ORS should not be given to children with red flag signs or symptoms [1][L3].

• NB: If oral rehydration fails, hospital admission is recommended [2][L3, RGA2].

Modified formulas:

• Routine use of lactose−free feeds is not recommended in patients managed in the community [2][L1, RGB].

• There is insufficient evidence to make recommendations on the use of diluted lactose-containing milk [2].


18 Following rehydration

Quick info:Following rehydration of the child [1,3][L3]:

• Encourage breast-fed babies to continue breastfeeding and intake of fluids.

• Give full-strength milk straight away.

• Avoid fruit juices and carbonated drinks until diarrhoea has stopped.

• Reintroduce the child's usual diet:

• Advise small, frequent meals throughout the day.

• Consider giving the following groups of children 5 mL/kg of ORS solution after each large watery stool [1][L3]:

• Younger than 1 year of age, particularly those younger than 6 months.



• More than two vomits in the previous 24 hours.

If dehydration occurs after rehydration, restart oral rehydration therapy [1][L3].References:Please see the care map's Provenance.

19 Follow up

Quick info:Further medical assessment should be considered if there is no improvement within 48 hours, or there is worsening of the child’soverall condition [3].The pathogens most frequently detected in children with persistent diarrhoea [2]:

• Rotavirus.

• Norovirus.

• Astrovirus.



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• Enteroaggregative Escherichia coli and atypical E. coli.

• Giardia.

• Cryptosporidium.

• Entamoeba histolytica.

Risk factors for persistent diarrhoea [2]:

• Age younger than 6 months, due to greater risk of exposure to rotavirus.

• Underlying chronic disease:

• Immune deficiency.

• Clostridium difficile is a major agent of severe diarrhoea in selected chronic diseases, such as:

• Inflammatory bowel disease.

• Oncologic conditions.

• Clinical condition – persistent diarrhoea is more common in children with:

• Loss of appetite.

• Fever.

• Vomiting.

• Mucous in stools.

• Lower socioeconomic status.


Diarrhoea in children and adolescents

___________________________________________________________________________________________

Provenance Certificate

Overview Editorial

approach Evidence Grading References

Guideline Development Group

Responsibilities Acknowledgements

Overview

This guideline document has been developed and issued by the Ministry of Public Health of Qatar (MOPH), through a process

which aligns with international best practice in guideline development and localisation. The guideline will be reviewed on a

regular basis and updated to incorporate comments and feedback from stakeholders across Qatar.

Whilst the MOPH has sponsored the development of the care map, the MOPH has not influenced the specific recommendations

made within it.

This care map was approved on 08 Dec 2016.

For information on changes in the last update, see the information point entitled 'Updates to this care map' on each page of the

care map.

Editorial approach

This care map has been developed and issued by the Ministry of Public Health of Qatar (MOPH), through a process which

aligns with international best practice in guideline development and localisation. The care map will be reviewed on a regular

basis and updated to incorporate comments and feedback from stakeholders across Qatar.

The editorial methodology, used to develop this care map, has involved the following critical steps:

Extensive literature search for well reputed published evidence relating to the topic.

Critical appraisal of the literature.

Development of a draft summary guideline.

Review of the summary guideline with a Guideline Development Group, comprised of practising physicians and subject

matter experts from across provider organisations in Qatar.

Independent review of the guideline by the Clinical Governance body appointed by the MOPH, from amongst

stakeholder organisations across Qatar.

Explicit review of the care map by patient groups was not undertaken.

Whilst the MOPH has sponsored the development of the care map, the MOPH has not influenced the specific

recommendations made within it.

Sources of evidence

The professional literature published in the English language has been systematically queried using specially developed,

customised, and tested search strings. Search strategies are developed to allow efficient yet comprehensive analysis of relevant

publications for a given topic and to maximise retrieval of articles with certain desired characteristics pertinent to a guideline.

For each guideline, all retrieved publications have been individually reviewed by a clinical editor and assessed in terms of

quality, utility, and relevance. Preference is given to publications that:

1. Are designed with rigorous scientific methodology.

2. Are published in higher-quality journals (i.e. journals that are read and cited most often within their field).

3. Address an aspect of specific importance to the guideline in question.


___________________________________________________________________________________________

Where included, the ‘goal length of stay’ stated within this guideline is supported by and validated through utilisation analysis of

various international health insurance databases. The purpose of database analysis is to confirm the reasonability and clinical

appropriateness of the goal, as an achievable benchmark for optimal duration of inpatient admission.

Evidence grading and recommendations

Recommendations made within this guideline are supported by evidence from the medical literature and where possible the

most authoritative sources have been used in the development of this guideline. In order to provide insight into the evidence

basis for each recommendation, the following evidence hierarchy has been used to grade the level of authoritativeness of the

evidence used, where recommendations have been made within this guideline.

Where the recommendations of international guidelines have been adopted, the evidence grading is assigned to the underlying

evidence used by the international guideline. Where more than one source has been cited, the evidence grading relates to the

highest level of evidence cited:

Level 1 (L1):

o Meta-analyses.

o Randomised controlled trials with meta-analysis.

o Randomised controlled trials.

o Systematic reviews.

Level 2 (L2):

o Observational studies, examples include:

Cohort studies with statistical adjustment for potential confounders.

Cohort studies without adjustment.

Case series with historical or literature controls.

Uncontrolled case series.

o Statements in published articles or textbooks.

Level 3 (L3):

o Expert opinion. o Unpublished data, examples include:

Large database analyses. Written protocols or outcomes reports from large practices.

In order to give additional insight into the reasoning underlying certain recommendations and the strength of recommendation,

the following recommendation grading has been used, where recommendations are made:

Recommendation Grade A1 (RGA1): Evidence demonstrates at least moderate certainty of at least moderate net

benefit.

Recommendation Grade A2 (RGA2): Evidence demonstrates a net benefit, but of less than moderate certainty, and

may consist of a consensus opinion of experts, case studies, and common standard care.

Recommendation Grade B (RGB): Evidence is insufficient, conflicting, or poor and demonstrates an incomplete

assessment of net benefit vs harm; additional research is recommended.

Recommendation Grade C1 (RGC1): Evidence demonstrates a lack of net benefit; additional research is

recommended.

Recommendation Grade C2 (RGC2): Evidence demonstrates potential harm that outweighs benefit; additional

research is recommended.

Recommendation of the GDG (R-GDG): Recommended best practice on the basis of the clinical experience of the

Guideline Development Group members.


___________________________________________________________________________________________

References

1. National Institute for Health and Care Excellence (NICE). Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management. Clinical guideline 84. London: NICE; 2009.

2. Guarino A, Ashkenazi S, Gendrel D et al. European Society for Pediatric Gastroenterology, Hepatology, and Nutrition/European Society for Pediatric Infectious Diseases evidence-based guidelines for the management of acute gastroenteritis in children in Europe: update 2014. J Pediatr Gastroenterol Nutr 2014; 59: 132-52.

3. Farthing M, Salam M, Lindberg G et al. Acute diarrhoea in adults and children: a global perspective. Milwaukee, WI;

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management. Arch Dis Child 2001;85:132–142.

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Publications; 2013.


___________________________________________________________________________________________

Guideline Development Group members

The following table lists members of the Guideline Development Group (GDG) nominated by their respective organisations and

the Clinical Governance Group. The GDG members have reviewed and provided feedback on the draft guideline relating to the

topic. Each member has completed a declaration of conflicts of interest, which has been reviewed and retained by the MOPH.

Guideline Development Group members

Name Title Organisation

Dr Khalid Jamal Abuhasima Senior Consultant Hamad Medical Corp

Dr Mouhammad Samer Hamwy Senior Paediatric Consultant Al Ahli Hospital

Dr Yasser Mohamed Mosli Senior Paediatric Consultant Al Emadi Hospital

Dr Mohamed Salem Nasralla

Saleh Specialist Family Medicine & Faculty Trainer

Primary Health Care

Corp

Responsibilities of healthcare professionals

This care map has been issued by the MOPH to define how care should be provided in Qatar. It is based upon a comprehensive

assessment of the evidence as well as its applicability to the national context of Qatar. Healthcare professionals are expected to

take this guidance into account when exercising their clinical judgement in the care of patients presenting to them.

The guidance does not override individual professional responsibility to take decisions which are appropriate to the

circumstances of the patient concerned. Such decisions should be made in consultation with the patient, their guardians, or

carers and should consider the individual risks and benefits of any intervention that is contemplated in the patient’s care.

Acknowledgements

The following individuals are recognised for their contribution to the successful implementation of the National Guidelines

project.

Healthcare Quality Management and Patient Safety Department of the MOPH:

Ms Huda Amer Al-Katheeri, Acting Director & Project Executive.

Dr Alanoud Saleh Alfehaidi, Guideline & Standardisation Specialist.

Dr Ilham Omer Siddig, Guideline & Standardisation Specialist.

Ms Maricel Balagtas Garcia, Guideline Standardisation Coordinator.

Dr Rasmeh Ali Salameh Al Huneiti, Research Training & Education Specialist.

Mr Mohammad Jaran, Risk Management Coordinator.

Hearst Health International:

Dr Mehmood Syed, Middle East Clinical Director & Project Clinical Lead.

Mr Michael Redmond, Clinical Programmes Manager.

Ms Deepti Mehta, Editorial and Research Manager.

Ms Rebecca Cox, Editorial and Research Team Leader.

Ms Shuchita Deo, Lead Editorial Assistant.

Ms Siobhan Miller, Editorial Assistant.

Ms Fatima Rahman, Editorial Assistant.


___________________________________________________________________________________________

Ms Tahmida Zaman, Editorial Assistant.

Ms Emma Ramstead, Information Specialist.

Dr Amy Glossop, Clinical Editor.

Dr Zara Quail, Clinical Editor.

Dr Sabine Fonderson, Clinical Editor.

Documents

Diarrhoea in children and adolescents - Pages - وزارة ... · Diarrhoea in children and adolescents ... *Red flag features that help to identify children at increased risk of